Running head: POLICY ANALYSIS WHITE PAPER 1

Policy Analysis White Paper

Kayla Azari
Barry University
POLICY ANALYSIS WHITE PAPER 2

Policy Analysis White Paper

Introduction to the Problem

The long fight for full practice for advanced practice registered nurses (APRNs) in

Florida finally bore fruits on March 11, 2020, when HB 607 was signed into law by President

Galvano and Governor DeSantis (npcouncilpbc, 2020). The approval of HB represents one of the

landmark bills ever signed into law by the state government of Florida. The bill provides new

dawn for APRNs as it will allow nurse practitioners (NPs) to practice without the supervision of

a physician which will lead to an improvement in health outcomes for Floridians. HB 607 will be

effective on July 1, 2020 (The Florida Senate, 2020). Florida joins other states across America

that have authorized APRNs to practice independently and autonomously.

HB 607 was filled in The Florida Senate on December 11, 2019. It was sponsored by

Rep. Carry Pigman and aimed at expanding the scope of physician assistants (PAs) and APRNs

to independent and autonomous practice without the supervision of physicians. Before APRNS

were given full practice, Florida law required them to practice within the confines of a

supervising protocol under the supervision of a physician (“House Bill 607 (2020) - The Florida

Senate,” 2019). APRNs believed that they possessed the requisite skills and knowledge to offer

their services independently and autonomously. The scope of practice for APRNs varies by state

and it is divided into three major categories namely: full, reduced, and restricted practice (E.

Peterson, 2017). Before Florida joined, 21 states across America had authorized NPS to exercise

full practice authority (FPA) (Brom, Salsberry, & Graham, 2018). The rest of the states had

maintained barriers to autonomous practice with 17 states being in the category of reduced

practice and the remaining 12 reported to having restricted practice (Altman et al., 2016). Florida
POLICY ANALYSIS WHITE PAPER 3

was among the 12 states that had denied APRNs a chance to work in full exercise of their skills

and knowledge.

The need for independent practice came amid the rising shortage of physicians in Florida.

As of 2018, it was reported that Florida had a physician to population ratio of 86.8 physicians

who were actively providing primary care per 100 population (“2019 State Physician Workforce

Data Report,” 2019). According to the 2019 annual report of physician workforce of the

Department of Health (DOH), this number was expected to reduce in the foreseeable future as

35% of the physicians in Florida are above the age of 60, where 12.5% have indicated their plans

to retire in five years to come (Desantis & Rivkees, 2019). The shortage of physician is reflected

across the United States and projections of demand and supply indicate that there will be more

demand than supply of PCPs (Primary Care Physicians) in states have reduced and restricted

practice compared to states that have independent practice. These reports showed the necessity

for allowing APRNs to work independently to fill the widening gap between PCPs and the

growing population.

Most, if not all, APRNs supported HB 607 and they have solidified their advocacy for

autonomous and independence practice through relevant bodies such as AANP (American

Association of Nurse Practitioners), FLANP (Florida Association of Nurse Practitioners), and

Florida Nurse Practitioner (“Network American Association of Nurse Practitioners,” 2019). This

report entails detailed background information and literature on NPs with much emphasis on

APRNs as qualified to practice autonomously. Also, it touches on the projected potential costs of

implementation, operation, and feasibility of success of the HB 607. Moreover, the report

highlights the impact of the bill on the community and equitability of care as well as

recommendations on the appropriate courses of action.

POLICY ANALYSIS WHITE PAPER 4

Background

Nurse practitioners have undergone many transformations since the 1960s. The role of

NPs was first created in 1965 by Loretta Ford, a nursing pioneer, who partnered with Henry

Silver, a pediatrician, to create a pediatric NP certificate program that would provide nurses with

relevant skills to provide primary care to patients (E. Peterson, 2017). In 1971, the state of Idaho

became the first to recognize the NP role where the scope of practice entailed diagnosis and

treatment (Brom et al., 2018). The journey towards independent practice for nurse practitioners

started in 1994 where five states (Montana, Alaska, Oregon, New Mexico, and Iowa) allowed

NPs to have FPA (Brom et al., 2018). The milestone step taken by the five states provided

confidence that NPs could offer primary care without a physician’s direct supervision. Since

then, some states have joined the league of independent practice while others such as Florida

have remained reluctant.

In Florida, an APRN used to practice in one of four major areas. These areas included

certified nurse-midwife (CNM), certified nurse practitioner (CNP), certified registered nurse

anesthetist (CRNA), and clinical nurse specialist (CNS) (“House Bill 607 (2020) - The Florida

Senate,” 2019). Currently, there are 32,877 actively licensed APRNs in Florida (“House Bill 607

(2020) - The Florida Senate,” 2019). The state of Florida was described as supervisory in terms

of APRNs autonomy where they were supposed to practice under a written protocol which

provided that an APRN can prescribe and administer any drug, order occupational and physical

therapy as well as diagnostic tests, initiate relevant therapies for various conditions, and execute

duties within one’s specialty (“Florida Association of Nurse Practitioners,” 2020). APRNs in

Florida were not allowed to sign such documents as death certificates; instead, the role had been
POLICY ANALYSIS WHITE PAPER 5

designated to a physician by the Florida Law (“House Bill 607 (2020) - The Florida Senate,”

2019).

APRNs in Florida continued to advocate against barriers that limited their practice. The

barriers included state laws, outdated models of reimbursement, federal policies, and institutional

cultures and practices (E. Peterson, 2017). The major arguments against the autonomous practice

were pegged on safety concerns. However, evidence from studies and reports has indicated that

APRNs provide health care services that are as safe as those provided by physicians (Altman et

al., 2016). The Institute of Medicine (IOM) in collaboration with Robert Wood Johnson

Foundation (RWJF) compiled a report, "The Future of Nursing: Leading Change, Advancing

Health," which advocated for independent practice for nurses and outlined that effective

policymaking should focus on improved data collection and enhanced information structure (E.

Peterson, 2017). This report has played a major role in persuading policymakers to understand

the provisions in the Nurse Practice Act, The Board of Nursing as well as Administrative rules in

a bid to make reforms on laws regarding the scope of practice. With such an understanding, it

was easier for the policymakers to comprehend the meaning of FPA according to AANP and

IOM on the "Future of Nursing" in their advocacy for autonomous and independent practice for

APRNs.

Literature Review

Allowing full practice for NPs goes a long way in ensuring quality primary care for

people in medically underserved areas (MUA) and those living in Healthcare professional

Shortage areas (HSPAs). In a study that was conducted by Xue et al., (2018), the researchers

wanted to compare the trends in the supply of NPs in MUA and HSPAs where independent

practice is allowed and in states with restrictive practice. They found a striking difference in NP
POLICY ANALYSIS WHITE PAPER 6

supply in MUA and HSPAs in FPA states as compared to supervisory states. Independent

practice was linked to high supply of NPs in HPSAs and MUA. The investigators concluded that

regulation plays a pivotal role in optimizing the capacity of NPs in underserved areas where

health care is needed the most. Thus, such a study can be used to suggest reforms on the scope of

practice for NPs.

Elimination of restrictive practices is key to improving the health system and realizing

economic benefits. Unruh et al., (2018), researched the benefits of autonomous practice for

APRNs in Florida. The investigators reviewed data from different research databases and

estimated variations that would occur in the supply of APRNs given independent practice laws.

Also, they estimated the health benefits and resultant health system. They found that APRNs in

active practice would increase by 11%, reducing the shortage of physicians. In addition, they

estimated that health care costs would drop significantly with each resident being able to save

$50 to $493. Moreover, independent practice was associated with additional jobs and increased

revenue for the state of Florida. As a result, removing regulations on restrictive practice for

APRNs can help improve health care delivery, reduce expenditure on health care, and improve

Florida’s economy in terms of revenue generation.

The fight for autonomy and independent practice for APRNs continues to face hostile

reactions, especially from physicians. For instance, the American College of Physicians is

strongly opposed the HB 607 as reported by Daytona News Journal. Through their lawyer, Chris

Nuland, they argue that the enactment of the bill is tantamount to removing from the health care

system. In addition, some physicians have come out to boldly oppose HB 607 (Florida, 2019).

Mark Dobbertein, an osteopathic and surgeon physician, in his address to the house committee

testified that in his 27 years of practice in Florida, he remains convinced that the physicians’
POLICY ANALYSIS WHITE PAPER 7

competence in the leadership of health care teams is unmatchable (Florida, 2019). The

physicians and their interest groups continued to be a stumbling block in the expansion of

nurses’ scope of practice in Florida. However, it is worth noting that the sponsor of HB 607,

Carry Pigman, is a medical doctor, argued that APRNs were equal to the task as he admitted that

the training and experience that APRNs possess is enough to allow them full autonomy

(Downey, 2020). Thus, it is evident some doctors have appreciated the fact that NPs should be

granted FPA.

APRNs can provide primary care services that supplement the services of PCPs.

Research has shown that in states where APRNs practice without the supervision of a physician,

it has been reported that there has been an increase of 16-35% in the utilization of healthcare, a

rise on quality of care, and reduction in cases of inappropriate usage of emergency rooms

(Udalova, & Traczynski, 2014). In another study, it was established that patient with chronic

illnesses who receive primary care from APRNs are usually treated following established

guidelines similar to those attended to by PCPs (Udalova, & Traczynski, 2014). In essence,

studies have proven beyond a reasonable doubt that APRNs are capable of working

independently.

The fight for independent practice is not meant to interfere with physicians' role in

medicine. According to "The Future of Nursing," the aim of the advocacy for FPA is not to

replace physicians. In its recommendation, it states that "advanced practice registered nurses

should be able to practice the full extent of their education and training,” (Altman et al., 2016).

Further, in an advocacy video that featured APRNs from Florida, they made it clear that they

possessed the qualifications and experience to practice independently. In the video, it was

evident that their plea was not to replace doctors but to be allowed to practice to the top of their
POLICY ANALYSIS WHITE PAPER 8

training and education (“APRNs Support Florida House Bill 607,” 2020). In the same vein, I

have interacted with my colleagues in the field of Doctor of Nursing Practice and they assert that

they have been performing the same tasks that their supervising physicians have been

performing. Thus, they found no reason to continue being supervised for duties that they have

been performing for years daily.

HB 607 requires that an APRN should be registered for autonomous practice if one

satisfies a certain criterion. According to the bill, before someone is registered to practice as a

PCP, one must have an unencumbered and an active Florida license and meet certain

requirements which include 3000 clinical hours of practice under the supervision of an actively

working physician within 5 years before registration request (The Florida Senate, 2020).

Moreover, the APRN should not have any record of disciplinary action within the 5 years.

Further, the APRN is required to have finished a pharmacology course at graduate level and

fulfill any other requirement that may be adopted by respective bodies. The registration shall be

renewed biennially where the renewal is supposed to coincide with the period of licensure

renewal. After being registered to practice independently, an APRN will have the right to

practice any specialized or advanced nursing act that is authorized for APRNs without a written

protocol or a physician's supervision. In addition, an APRN will have the right to perform most

of the duties that have previously been left under the jurisdiction of a physician such as

examination of law enforcement officers, suspected victims of child abuse, and pilots (The

Florida Senate, 2020). The passing of the bill was major milestone in granting the long-awaited

FPA for APRNs in Florida.

POLICY ANALYSIS WHITE PAPER 9

Projected Cost of Implementation, Operation, and Feasibility of Success

The cost of implementation, operation, and feasibility of success is provided under the

fiscal analysis and economic impact statement of the HB 607 as passed by the Health Quality

Subcommittee. The overall cost of implementation is projected to be $236,805 (“House Bill 607

(2020) - The Florida Senate,” 2019). This amount is as a result of the cost of operation.

Department of Health (DOH) will have to incur costs linked to the regulation of independent

APRNs. Thus, DOH estimates that 3.5 full-time equivalents (FTE) positions shall be needed for

the implementation of the bill’s provisions. The positions required shall involve two functional

areas. One of the areas entails processing and the other involves investigation and prosecution.

Under the area of processing, DOH requires one regulatory expert whose responsibilities

shall involve analyzing, denying or approving registration applications, and updating of

practitioner profiles. Subsequently, in the department of investigation and prosecution, DOH

shall require one attorney and 1.5 FTE investigative experts whose responsibilities will entail

reviewing complaints to determine whether they are legally necessary for investigation and

prosecution. The salary rate for the two functional areas is projected to be $183,895 and the

recurring expenditure associated with the two areas is estimated to be $219,089. The estimated

cost for assessment of the feasibility of success is categorized under non-recurring funds which

adds up to $17,716 (“House Bill 607 (2020) - The Florida Senate,” 2019). According to the bill,

all funds are appropriated from the Medical Quality Assurance Trust for the implementation of

the bill’s requirements.

Impact of HB 607 To the Community and Equitability of Care

POLICY ANALYSIS WHITE PAPER 10

HB 607 bill has both economic and health benefits to the community. In the recent past,

health care cost has been on the rise and such a trend has been a major point of concern for

families, government, businesses, individuals and the greater society (“House Bill 607 (2020) -

The Florida Senate,” 2019). The reason for the rising cost is that more people have access to

health care coverage but the number of health workers is gradually reducing. The Federal Trade

Commission (FTC) of the U.S. contends that limiting the scope of practice for APRNs is anti-

competitive, reduces the market pressures of competition, reduces service delivery, and limits the

hours of service (Ramirez et al., 2014). FTC argues that the elimination of such constraints, will

not only increase access to quality health care but also will lead to price competition which will,

in turn, the reduce cost of healthcare. Allowing APRNs to practice autonomously means that

their scope of practice shall be expanded and they shall be able to reach more patients, leading to

a substantial decrease in expenditure on healthcare.

HB 607 will go a long way towards ensuring equitability for healthcare. Carry Pigman,

the sponsor of the bill states that allowing APRNs to practice autonomously will extend

healthcare to medically underserved areas as well as those areas that experience a shortage of

healthcare professionals Hendren, L. (2019). In a study that was conducted by Cochrane

Collaboration, the researchers found that APRNs who acted as PCPs attained equal health care

outcomes for their patients (Laurant, Sergison, & Sibbald, 2018). Also, their patients reported a

higher level of satisfaction. Moreover, the patients had ample time for consultation unlike when

receiving services from a physician. Independent and autonomous practice for APRNs will

enhance equitability for healthcare which means that every patient shall have access to quality

healthcare, their satisfaction will be high, and they shall have sufficient time for consultation,

which is key to better health outcomes.

POLICY ANALYSIS WHITE PAPER 11

Conclusion and recommendations

This report sees the passing of HB 607 into law as the only way the residents of Florida

can be assured of equitable and cost-effective health care. Specifically, it enables every Floridian

to understand that APRNs have the competency to practice without a written protocol or a

physician’s instructions. While physicians continue to counter efforts by APRNs in the fight for

autonomy citing the safety of patients, it has been proven that APRNs can offer primary care and

achieve the same or better results compared to the physicians. Additionally, no state has ever

turned back after granting FPA to NPs, which is an indication that independent practice has

contributed to the enhancement of healthcare delivery in such states.

This report recommends two courses of action that will make HB 607 a success. First, it

recommends that all APRNS should adhere to the requirements of the bill to ensure a smooth

transition to full practice. Also, it recommends that APRNs should continue working closely

with physicians to create a collaborative healthcare system for the betterment of health outcomes

for Floridians. As nurse leaders, we are dedicated to supporting HB 607 through every means

possible to show our commitment to the two recommended courses of action. We intend to

follow the requirements of HB 607 to the letter and ensure that we maintain a working

relationship with physicians to show the Floridians that our aim in the fight for autonomy was

only meant for gaining FPA but also to ensure that they enjoy more access to direct healthcare

services.
POLICY ANALYSIS WHITE PAPER 12

References

2019 State Physician Workforce Data Report. (2019). Retrieved from store.aamc.org website:

https://store.aamc.org/2019-state-physician-workforce-data-report.html

Altman, S. H., Adrienne Stith Butler, Shern, L., For, C., Wood, R., & Wood, R.

(2016). Assessing progress on the Institute of Medicine report The future of nursing.

Washington, Dc: The National Academies Press.

American Association of Nurse Practitioners. (2019, September 4). Retrieved from American

Association of Nurse Practitioners website: https://www.aanp.org/

APRNs Support Florida House Bill 607. (2020). Retrieved February 17, 2020, from The Florida

Nurse Practitioner Network | ENP Network website: https://fnpn.enpnetwork.com/nurse-

practitioner-news/208852-aprns-support-florida-house-bill-607?

utm_medium=email&utm_source=group&utm_campaign=batch_announcement_promoti

on

Brom, H. M., Salsberry, P. J., & Graham, M. C. (2018). Leveraging health care reform to

accelerate nurse practitioner full practice authority. Journal of the American Association

of Nurse Practitioners, 30(3), 120–130. https://doi.org/10.1097/jxx.0000000000000023

Desantis, R., & Rivkees, S. (2019). 2019 Physician Workforce Annual Report. Retrieved from

http://www.floridahealth.gov/provider-and-partner-resources/community-health-

workers/physician-workforce-development-and-

recruitment/2019DOHPhysicianWorkforceReport-10-30-19.pdf

Downey, R. (2020, January 28). Cary Pigman corrals nearly 200 nurse anesthetists to support

nurse independence. Retrieved February 17, 2020, from Florida Politics - Campaigns &

Elections. Lobbying & Government. website:

POLICY ANALYSIS WHITE PAPER 13

https://floridapolitics.com/archives/317276-cary-pigman-corrals-nearly-200-nurse-

anesthetist-to-support-nurse-independence?

fbclid=IwAR1OivuCSOo0ohoK6SM5kB14W-

c4RzzTWMgBWfiy_7ETPSh3pf_Sz9yn25A

E. Peterson, MS, APRN, AOCNP, M. (2017). Barriers to Practice and the Impact on Health

Care: A Nurse Practitioner Focus. Journal of the Advanced Practitioner in

Oncology, 8(1). https://doi.org/10.6004/jadpro.2017.8.1.6

Florida Association of Nurse Practitioners. (2020). Retrieved February 17, 2020, from

www.flanp.org website: https://www.flanp.org/

Florida, C. S., The News Service of. (2019). Expanded role for nurses in Florida gets House

support. Retrieved from Daytona Beach News-Journal Online website:

https://www.news-journalonline.com/news/20191211/expanded-role-for-nurses-in-

florida-gets-house-support

Hendren, L. (2019). Nurse practitioners could soon practice without doctor supervision in

Florida. Retrieved from 10NEWS website:

https://www.wtsp.com/article/news/health/nurse-practitioners-could-soon-practice-

without-doctor-supervision-in-florida/67-a7ab0f42-38c5-463e-9230-e2640cd7386a

House Bill 607 (2020) - The Florida Senate. (2019). Retrieved February 17, 2020, from

www.flsenate.gov website: https://www.flsenate.gov/Session/Bill/2020/607/?

Tab=Analyses

Laurant, M., Sergison, M., & Sibbald, B. (2018). Substitution of doctors by nurses in Primary

Care. Cochrane Database of Systematic Reviews, (7).

https://doi.org/10.1002/14651858.cd001271
POLICY ANALYSIS WHITE PAPER 14

npcouncilpbc. (2020). BREAKING NEWS: Speaker Oliva thanks Gov. DeSantis, President

Galvano after Governor Signs APRN Bill Into Law. Retrieved from The Nurse

Practitioner Council of Palm Beach County | ENP Network website:

https://npcouncilpbc.enpnetwork.com/nurse-practitioner-news/209354-breaking-news-

speaker-oliva-thanks-gov-desantis-president-galvano-after-governor-signs-aprn-bill-into-

law?

utm_medium=email&utm_source=group&utm_campaign=batch_announcement_promoti

on

Ramirez, Edith Chairwoman, Brill, J., Ohlhausen, M. K., & Wright, Joshua D. Commissioner.

(2014). Policy Perspectives: Competition and the Regulation of Advanced Practice

Nurses. Retrieved from https://www.ftc.gov/system/files/documents/reports/policy-

perspectives-competition-regulation-advanced-practice-

nurses/140307aprnpolicypaper.pdf

The Florida Senate. (2020). 2020 Bill Summaries - The Florida Senate. Retrieved from

www.flsenate.gov website:

https://www.flsenate.gov/Committees/BillSummaries/2020/html/2294

Udalova, V., & Traczynski, J. (2014). Nurse practitioners: A solution to America’s primary care

crisis. Retrieved from American Enterprise Institute - AEI website:

https://www.aei.org/research-products/report/nurse-practitioners-a-solution-to-americas-

primary-care-crisis/

Unruh, L., Rutherford, A., Schirle, L., & Brunell, M. L. (2018). Benefits of Less Restrictive

Regulation of Advance Practice Registered Nurses in Florida. Nursing Outlook, 66(6),

539–550. https://doi.org/10.1016/j.outlook.2018.09.002
POLICY ANALYSIS WHITE PAPER 15

Xue, Y., Kannan, V., Greener, E., Smith, J. A., Brasch, J., Johnson, B. A., & Spetz, J. (2018).

Full Scope-of-Practice Regulation Is Associated with Higher Supply of Nurse

Practitioners in Rural and Primary Care Health Professional Shortage Counties. Journal

of Nursing Regulation, 8(4), 5–13. https://doi.org/10.1016/s2155-8256(17)30176-x